From drug therapy failures to laser therapy victory: A case report and literature review of lupus miliaris disseminatus faciei resolution

Key Clinical Message Pulsed dye laser (PDL) has proven effective in resolving lupus miliaris disseminatus faciei (LMDF) where drug therapies have failed with a lack of treatment consensus for LMDF, considering early PDL intervention is crucial to achieve resolution without scarring, prevent relapse, and enhance overall treatment outcomes. Abstract Lupus miliaris disseminatus faciei (LMDF) is a rare inflammatory and granulomatous dermatologic disease that primarily affects the face. The optimal treatment for LMDF remains controversial, and there is a lack of consensus on the most effective therapy. This case report highlights the successful use of a 595 nm pulsed dye laser (PDL) in the treatment of LMDF following unsuccessful drug therapy. A 28‐year‐old male presented with reddish‐brown eruptions on his face that had persisted for several months. Clinical examination revealed discrete dome‐shaped eruptions in clusters on the central area of the face. Histopathological examination confirmed the diagnosis of LMDF, based on the presence of epithelioid granulomas with central caseous necrosis. Previous treatment with an oral isotretinoin and methotrexate combination also failed to yield satisfactory results. After discontinuing drug therapy, the patient underwent five sessions of PDL treatment. Ten days after the first session, the eruptions began to regress without scarring. Subsequent PDL sessions led to the complete resolution of the eruptions. The patient experienced no relapse during the follow‐up period. This case report suggests that PDL treatment may be an effective option for LMDF, particularly in cases where drug therapy has failed. Early initiation of laser treatment may prevent scarring, minimize the adverse effects associated with drug therapy, and reduce the risk of disease relapse. Further research and controlled trials are needed to establish the efficacy of laser therapy in the treatment of LMDF.

for LMDF remains controversial, and there is a lack of consensus on the most effective therapy.This case report highlights the successful use of a 595 nm pulsed dye laser (PDL) in the treatment of LMDF following unsuccessful drug therapy.
A 28-year-old male presented with reddish-brown eruptions on his face that had persisted for several months.Clinical examination revealed discrete domeshaped eruptions in clusters on the central area of the face.Histopathological examination confirmed the diagnosis of LMDF, based on the presence of epithelioid granulomas with central caseous necrosis.Previous treatment with an oral isotretinoin and methotrexate combination also failed to yield satisfactory results.
After discontinuing drug therapy, the patient underwent five sessions of PDL treatment.Ten days after the first session, the eruptions began to regress without scarring.Subsequent PDL sessions led to the complete resolution of the eruptions.The patient experienced no relapse during the follow-up period.This case report suggests that PDL treatment may be an effective option for LMDF, particularly in cases where drug therapy has failed.Early initiation of laser treatment may prevent scarring, minimize the adverse effects associated with drug therapy, and reduce the risk of disease relapse.Further research and controlled trials are needed to establish the efficacy of laser therapy in the treatment of LMDF.

| INTRODUCTION
Lupus miliaris disseminatus faciei (LMDF) is a distinct, uncommon inflammatory and granulomatous dermatologic disease that primarily affects the medial part of the face. 1,2However, it has also been reported with extrafacial manifestations. 3Despite its name, there is no evidence of acid-fast bacilli or Mycobacterium tuberculosis DNA in the lesions. 4The clinical manifestation of the disease includes discrete reddish-brown dome-shaped eruptions in multiple clusters scattered across the face, mainly around the lower eyelids and mid-face. 5,6Histopathology of the lesions consistently demonstrates epithelioid granulomas, mostly with central caseous necrosis. 7Although several treatments are suggested in the literature for this disease, there is no unified protocol for therapy.Due to the scarcity of studies, the optimum treatment remains controversial. 8,9Laser therapy is known as an effective option in the treatment of various skin diseases, as well as scars caused by inflammatory processes and skin damage. 10,11This study presents a case of LMDF with failed drug therapy that achieved a satisfactory result through treatment with a 595 nm pulsed dye laser (PDL).

| CASE HISTORY/ EXAMINATION
A 28-year-old male was referred to the dermatology clinic with a history of reddish-brown eruptions on his face that had persisted for 10 months.According to the patient's clinical history, the eruptions began to appear 4 months ago, primarily around the upper lip, nose, and lower eyelids.The lesions were not scaling, exfoliating, pruritic, or painful; however, some of them were crusted.He reported no known triggers for the onset or worsening of the lesions.Three months after the onset of the condition, a physician prescribed oral doxycycline and topical mometasone furoate ointment for 1 month, but no response or improvement was observed.During our clinical examination, we observed brown to red discrete maculopapular, acne-like eruptions in clusters at different stages, ranging from early-phase lesions to those that had healed with scarring.These lesions measured between 1 to 5 mm and appeared in the central area of his face, including around the lower eyelids, upper lip, and nose (Figure 1A,B).

| METHODS
Histopathological examination of a representative lesion revealed epithelioid multinucleated giant cells, lymphohistiocytic infiltration in the periphery, and caseous necrotic material in the center.Mild infiltration of eosinophils and mast cells was also noted (Figure 2A,B).Furthermore, hyperpigmentation of the basal layer in the overlying epidermis was observed.A thorough microscopic investigation of the biopsied tissue was not consistent with sarcoidal-type granulomas, mucin deposition, or Demodex mites.This granulomatous tissue pattern, characterized by central caseous necrosis within follicular units, was consistent with LMDF.Additionally, periodic acid-Schiff (PAS) and Ziehl-Neelsen staining were negative for fungal elements and acid-fast bacilli.
The patient reported no history of previous travel to endemic regions for Mycobacterium tuberculosis or prior exposure to an affected individual.A chest X-ray was also unremarkable.
After confirming LMDF, oral isotretinoin was administered at a daily dose of 20 mg.However, after 2 months of treatment, the response was unsatisfactory, and liver enzyme levels began to rise.Consequently, the isotretinoin dosage was reduced to 20 mg every other day, and oral methotrexate was added to the regimen at a dosage of 7.5 mg per week for 6 weeks.After 6 weeks of combination therapy with isotretinoin and methotrexate, the results remained unsatisfactory.Therefore, while discontinuing the combination therapy, pulsed dye laser (PDL) treatment was initiated, using a power of 6 J/cm 2 , a pulse width of 0.5 milliseconds, and a wavelength of 595 nanometers.
Ten days after the first laser treatment session, the eruptions began to regress without scarring.PDL therapy was continued for an additional four sessions, with 1 month between each session.At the end of the fifth session, the eruptions were completely resolved without scarring (Figure 1C,D).

| CONCLUSION AND RESULTS
However, the previous scars, either due to the spontaneous healing of the eruptions or from the drug therapy period, remained.The patient was evaluated five and 12 months after the end of treatment, and no relapse was noted.The timeline of the treatment and progress is presented in Figure 3.

| DISCUSSION
Fox reported the first description of LMDF in 1878 as a disease simulating acne. 12As a granulomatous dermatosis, the categorization of LMDF has fluctuated among various granulomatous dermatopathological disorders. 6It has been suggested that LMDF is related to Mycobacterium tuberculosis and has been referred to as Lewandowsky's rosacea-like tuberculid, 13 micropapular tuberculoid, 14 or Lupoid rosacea. 15However, the presence of acid-fast T A B L E 1 Features of the last studies on the laser.

Size
Prior drug treatment

Efficacy of laser treatment Follow up
Jih et al. 24  bacilli has not been demonstrated in the lesions. 4,7,16,17or decades, LMDF was assumed to be a variant of granulomatous rosacea. 4In contrast, LMDF's tendency toward self-regression, the absence of systemic manifestations such as flushing or telangiectasia, and the lack of vasculitis suggest that LMDF is a distinct dermatosis with its own specific features. 2,18In the early 2000s, Skowron et al. 1 described LMDF as a distinctive dermatosis and proposed the acronym "FIGURE" to represent Facial Idiopathic Granulomas with Regressive Evolution.FIGURE captures the disease's characteristics without implying a connection to rosacea, tuberculosis, or other dermatoses. 1 LMDF or FIGURE naturally tends to regress spontaneously; however, the long disease course often results in residual disfiguring pitted scars, necessitating effective treatment. 19arious treatments have been mentioned for this challenging disease, including topical or systemic isotretinoin, antibiotics, corticosteroids, immunomodulators, or combinations of multiple drugs. 20,21Intralesional corticosteroid injections have also been reported. 19Fewer than 300 LMDF cases have been documented, and few cross-sectional studies have been conducted, albeit without a control group. 4,17,22Consequently, inconsistency in the treatment of LMDF is to be expected.Most suggested treatments have been unsatisfactory for several reasons: first, the disease course is lengthy, and due to the lack of a control group, it is unclear whether regression of the lesions is attributable to the self-resolving nature of LMDF or the medications used 7,19,22,23 ; second, the drugs may cause adverse effects 24 ; and third, preventing residual pitted scars is essential.Many reports in the literature that suggest drug therapy as an effective treatment do not mention the status or improvement of residual scars after treatment. 4,6,7,19Additionally, the absence of recurring eruptions should also be considered a criterion for successful treatment.
5][26] Kang et al. 25 utilized a carbon dioxide laser in combination with 100% trichloroacetic acid to address the residual scars of LMDF.Before laser treatment, the patient's eruptions had been reduced through drug therapy, including ethambutol, rifampin, and pyrazinamide.Jih et al. 24 used a 1450 nm diode laser after multiple failures with drug therapies and successfully resolved eruptions without scarring.Beleznay et al. 20 reported a case of LMDF with poor response to various treatments, including low fluence Nd:YAG 1064-nm laser and one session of 532-nm frequency-doubled Nd:YAG, as well as two sessions of 595-nm pulsed dye laser (PDL).The patient's eruptions finally regressed without scarring after treatment with a nonablative fractionated 1565-nm erbium-doped fiber laser.Six years after Beleznay et al., Ma et al. reported a case of LMDF that was successfully treated with 595-nm PDL in combination with oral prednisolone, hydroxychloroquine, and isotretinoin. 26he results of the current study are consistent with those of Ma et al. 26 ; however, in our case, the drugs were discontinued first, followed by the initiation of PDL sessions without combination therapy.
Despite the limited treatment options for LMDF, our results, along with previous findings, suggest that laser therapy (595-nm PDL or 1450-nm diode laser) may be more effective than multiple courses of drug therapy.Although controlled trials with larger sample sizes are needed to establish the efficacy of treatments, we recommend initiating laser therapy earlier to alleviate eruptions without scarring, avoid multiple drug failures and their side effects, prevent disfiguring scars, and reduce the risk of disease relapse.
Committee of the Iran University of Medical Sciences in all stages.

CONSENT
Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

TRANSPARENCY DECLARATION
Authors declare that the manuscript is an honest, accurate, and transparent.No important aspect of the study is omitted.

ORCID
acne agminata, granulomatous dermatosis, LMDF, lupus miliaris disseminatus faciei, pulsed dye laser F I G U R E 1 (A and B) discrete domeshaped maculopapular eruptions are visible within around lower palpebrae and adjacent to nose.(C and D) Few days After first session of laser treatment, eruptions began to regress without scarring.Scars prior to laser treatment still remained.

F I G U R E 2
Histopathologic examination revealed Langhans giant cells, or possibly epithelioid and multinucleated giant cell infiltration, along with central caseous necrosis.(A) ×40, (B) ×100.F I G U R E 3 The patient's treatment timeline, indicating the difference between the satisfactory treatment after laser treatment in contrast with the drug therapy.